By Vishal Kumar Singh
New Delhi: Everyday, thousands of Indians mostly children are bitten by dogs. For most, it’s an everyday street hazard. But behind each bite lurks the threat of rabies, a disease that is entirely preventable yet still kills an estimated 18,000–20,000 Indians every year, according to World Health Organisation (WHO).
India carries the world’s heaviest burden of rabies deaths, accounting for more than one-third of global fatalities. Children are hit the hardest, with nearly half of all cases occurring in those under 15, often because their bites go unnoticed or untreated in time.
The paradox is painful as the effective vaccines and life-saving rabies immunoglobulin (RIG) exist, yet people continue to die either because treatment starts too late, supplies are missing, or awareness is poor. The Supreme Court’s recent intervention on the issue of stray dogs has once again thrown the spotlight on India’s preparedness to deal with this silent but deadly threat.
In this article, ETHealthworld examines the cracks in India’s rabies prevention system, explores why patients sometimes die despite completing the full vaccine course, and asks the urgent question, can the country finally close the gap between medical possibility and public health reality?
Why Do Patients Still Die Despite Vaccination?
It is one of the most troubling questions families ask when tragedy strikes: “If my relative took all the injections, why did they still die?”
Dr. Swadesh Kumar, Cluster Head (Emergency and Ambulance Services), Dharamshila Narayana Hospital, Delhi, and Narayana Hospital, Gurugram, explains that rabies can sometimes outpace the body’s ability to respond.
“Sometimes the vaccine is started too late. Rabies can enter the nervous system within hours. If the wound was not cleaned properly at the start or if the first dose was delayed, the vaccine may not have had enough time to protect the patient. In severe cases like deep bites, multiple wounds or bites on the face, vaccination alone may not be enough. These situations demand rabies immunoglobulin (RIG) alongside the vaccine,” he says.
Other factors can also undermine vaccine effectiveness. Improper storage conditions, such as exposure to heat that compromises vaccine potency, and errors in administration — injecting at the wrong site — can reduce protection. Host factors matter too. “Children, malnourished patients or those with weak immune systems sometimes fail to mount the full defence,” Dr. Kumar adds.
Dr. Neha Mishra, Consultant, Infectious Diseases, Manipal Hospital, reinforces that both host immunity and bite site play a role. “People with immunodeficiencies or on immunosuppressive therapy may not mount adequate response to immunisation.
When the part of the body rich in nerves is affected, there may be faster spread of the virus, without providing sufficient time for the vaccine to act,” she explains. She also notes that unusually long incubation periods have been documented — in some cases, as long as 20 years.
At Fortis Gurgaon, Consultant in Infectious Diseases Dr. Neha Rastogi notes that true vaccine “breakthroughs” are rare. “In recent systematic reviews, the rate of occurrence was about one per cent. Most of these are linked to late reporting, improper schedules, non-availability of immunoglobulin, or lapses in cold-chain maintenance. The majority of rabies deaths are still preventable if protocols are followed,” she says.
Rabies Immunoglobulin: The Missing Link in PEP
If the vaccine is the long-term defence, RIG provides immediate protection. Unlike the vaccine, which takes time to stimulate the immune system, RIG contains pre-formed antibodies that neutralise the virus at the site of entry.
“RIG is part of post-exposure prophylaxis. It acts immediately upon administration to neutralise the virus,” explains Dr. Mishra. “This bridges the vulnerable window until the vaccine begins to work.”
There are two types of Rabies immunoglobulin: uman derived rabies immunoglobulin(HRIG) and equine-derived rabies immunoglobulin (ERIG). HRIG is safer but costly and scarce. ERIG is more affordable but carries risks of allergic reactions. In recent years, monoclonal antibody (mAb) preparations like Rabishield and Twinrab have been introduced as WHO-endorsed alternatives.
Access, however, remains patchy. Dr Kumar admits: “In theory, every Category III bite should receive RIG. In practice, only a fraction of patients do. Vaccines are reasonably accessible, but RIG shortages are striking. Families often have to search across pharmacies or shift hospitals.”
Dr. Rastogi cites a recent facility survey: anti-rabies vaccine (ARV) is available at ~80% of public facilities, but RIG at only approximate 40–50 per cent , with wide regional variation. “This mismatch between vaccine and RIG supply is one of the weakest points in the system,” she warns.
Who Is Most at Risk?
Experts agree that while rabies can affect anyone, children and immunocompromised patients remain especially vulnerable. “Children are more vulnerable, both biologically and socially,” says Dr. Kumar.
“A small child’s body mass means a dog’s bite delivers a proportionally higher viral load. Bites also tend to land on the face or upper body, closer to the brain. Add to this the fact that children may not immediately tell their parents about a minor scratch, and treatment often begins late.”
Immunocompromised patients face a different challenge. According to Dr. Rastogi, they require a five-dose vaccine schedule with mandatory RIG, because their immune systems often fail to produce enough antibodies after standard regimens. Dr. Mishra adds that in such cases, measuring antibody titers post-PEP can guide further care, though this is rarely done outside specialised centres.
Seasonal and Behavioural Triggers
Patterns in bite cases also reveal important trends. Dr. Ajay Nair, Senior Consultant in Internal Medicine at Narayana Hospital, Jaipur, notes, “The monsoon months see more dog bites, likely due to changes in animal behaviour and food scarcity. Festival seasons, particularly those involving fireworks, also trigger spikes as frightened dogs lash out.”
Dr. Mishra observes a rise in summer, when children spend more time outdoors, while Dr. Rastogi points to post-monsoon surges, often linked to waste accumulation and increased stray density. Together, these insights underline the importance of anticipating seasonal peaks and stockpiling supplies accordingly.
Strengthening Post-Exposure Prophylaxis (PEP)
If rabies is almost always fatal, it is also almost always preventable — provided PEP is timely and complete. Experts stress that PEP begins not in a hospital, but at the site of the bite.
“Perhaps the most powerful tool against rabies is still the simplest: proper wound care,” says Dr. Nair. “Washing a bite with soap and water for 15 minutes immediately reduces the viral load drastically. Yet many patients arrive with wounds smeared with turmeric, oil or chilli powder. Vaccines and RIG matter, but they cannot undo the damage if the virus is given a head start.”
India’s PEP system, however, struggles with gaps in access, adherence, and affordability. Dr. Nair recommends a multi-pronged strategy like having a intradermal vaccination the standard to stretch supplies, establishing 24×7 PEP corners for immediate wound washing and first doses, building buffer stocks with expiry tracking dashboards to prevent stock-outs. Capping retail prices and reimburse patients when asked to buy outside.
Stock HIV, hepatitis B, and tetanus PEP alongside rabies vaccines. Most importantly training frontline staff and use SMS reminders for follow-up doses.
Dr. Rastogi echoes these points with system-level precision and informed that maintaining buffer stocks for ARV and RIG/mAbs, creating fast-track triage for Category III bites. Train staff on wound irrigation, setting up a helpline to track real-time RIG locations, and monitoring stocks with cold-chain dashboards linked to district nodes are crucia, as these align with NRCP manuals and the NAPRE framework.
Dr. Kumar highlights that India’s vaccine availability problems are not rooted in production but in distribution. “In large city hospitals, supplies are usually adequate. But in rural areas, shortages remain common. The problem lies less in production and more in logistics — cold-chain transport, reliable forecasting, and timely procurement. When any of these fail, patients bear the cost.”
Policy, Preparedness, and the SC Order
Pointing to the policy landscape, Dr Mishra said, “There is a national rabies program in place, which focuses on strengthening district and PHC hospital facilities to tackle rabies.
Indian public health services are constantly working in the direction of preparedness for rabies, availability of vaccine and RIG, improved supply chains and capacity building.”
Yet implementation gaps remain. In Delhi-NCR, for instance, Dr Kumar notes that rabies vaccines are usually in stock at government and private hospitals, but RIG is a different story. “We frequently see patients who have already received the first vaccine dose elsewhere but were referred here because the other centre had no RIG. Private hospitals may stock human RIG, but at a price that puts it out of reach for many families. Public facilities mostly rely on equine RIG, which often runs out.”
The Supreme Court’s directive to relocate stray dogs to shelters has added another layer of complexity. While some see potential benefits, others warn of unintended consequences.
Dr. Mishra is cautiously optimistic: “Sheltering of stray dogs probably would help to bring down the number of rabies cases.”
Dr. Nair is more sceptical, said, “Relocation without mass vaccination or sterilisation risks shifting the problem rather than solving it. Sustainable control requires long-term dog vaccination and birth control, not just moving animals.”
Taking a nuanced view, Dr. Rastogi, said, “Risk depends on execution. Overcrowded, under-vaccinated shelters can amplify transmission. Emptying territories without parallel vaccination and sterilisation may create a ‘vacuum effect,’ drawing in unvaccinated dogs. With MCD already flagging staff and capacity gaps, implementation is a major concern.”
The Way Forward: Awareness and Accountability
Despite advances in vaccines and the presence of a national programme, experts agree that rabies control ultimately hinges on awareness and accountability.
“Every rabies death is a tragedy because every rabies death is avoidable,” says Dr. Nair. “Until supply chains are strengthened and public awareness deepens, doctors will continue to fight a disease that should have been consigned to history.”
Dr. Rastogi, said, “Prevention is the cure in rabies. Timely wound washing, correct PEP, and public understanding of the window period are the keys.”
As dog bite cases rise and the country debates the future of stray dog management, the message from clinicians is clear: vaccines and immunoglobulin save lives, but only if they reach patients quickly, reliably, and affordably.
